The Sixth Annual Health Insurance Exchange Conference

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Photo: Hoag LevinsConvened in the Penn Law School's Fitts Auditorium, the 6th Annual Health Insurance Exchange Conference opened with a keynote panel consisting of (l to r) Stephen Parente, PhD, MPH, from the University of Minnesota's Carlson School of Management, John McDonough, DrPH, MPA, of Harvard's T.H. Chan School of Public Health, and Joel Ario, Managing Director of Manatt Health Solutions at Manatt, Phelps & Phillips, LLP. See the photo page from the event.

On September 13 and 14, 2018, more than 80 senior policymakers, researchers, and state health insurance exchange administrators and insurance commissioners gathered at the University of Pennsylvania Law School for the Sixth Annual Health Insurance Exchange Conference. Jointly hosted by Penn Law, Penn LDI, and Princeton University's Center for Health and Wellbeing, this year’s event focused on how states are pursuing different paths for the individual insurance market, from stabilization to segmentation to expansion. Attendees spent the nonpartisan, off-the-record workshop discussing the latest issues and research surrounding the health insurance exchanges, through which most people buying their own health insurance purchase individual coverage.

A few key themes emerged from this year’s event. First, it is clear that states are concerned about the stability of the individual market and are working to counterbalance continued uncertainty at the federal level. States’ approaches, however, have varied depending upon the current state of their market and their experiences after Affordable Care Act (ACA) implementation. While some states have seen premium growth stabilize following the ACA, others have experienced steep premium increases – up to 300% – and are pursuing opportunities to lower premiums. A number of states are worried that expansion of non-ACA compliant Association Health Plans (AHPs) and Short-Term Limited Duration Plans (STLDs) could create adverse selection by taking healthier enrollees away from the exchanges and driving up premiums for those who remain. Others were less concerned about these plans being widely available, but more concerned that they are being falsely marketed to consumers as “comprehensive” coverage when they offer reduced or limited benefits.

The individual mandate, the ACA provision that requires all individuals to have health insurance or face a tax penalty, was also a frequent topic of conversation. Some attendees were not concerned about the elimination of the mandate’s tax penalty in 2019, since they believed the mandate had not played a significant role in driving exchange enrollment in their state. Meanwhile, others are pursuing adoption of a state-level mandate as part of a market stabilization strategy. Overall, lowering health care costs – especially around cost-sharing and drug prices – remains a top priority across states, as well as preventing risk pool fragmentation, supporting exchange enrollment, and ensuring adequate insurer competition to prevent price hikes.

Second, a number of attendees pointed to states’ efforts to promote and strengthen the exchanges. States’ successes were primarily attributed to their willingness to innovate and leverage flexibility in federal and state policy. For instance, seven states have pursued reinsurance programs to reimburse insurers for high-cost claims, and no state will have a county without an insurer in 2019. At the same time, many attendees remained concerned about the loss of federal cost-sharing reductions (CSRs), which required insurers to help defray the costs of medical care for especially low-income enrollees. Last year, a number of states increased the premiums in their silver-level plans to make up for lost federal CSRs—a practice called “silver-loading.” Because federal subsidies to individuals are based on silver plan premiums, silver-loading meant that subsidized enrollees were protected from these premium increases. States were concerned that the Trump administration could ban this practice in the future; for now, estimates suggest that over 40 states are expected to engage in some form of silver-loading in 2019.

Third, attendees made numerous predictions about the federal legislative landscape for health care in 2019, which largely will depend on which party controls Congress after the 2018 elections. Some predicted that Republicans may make another attempt at broad ACA repeal, while others suggested that efforts to change the ACA could be more marginal. Attendees also predicted that Democrats could pursue smaller health policy changes and agenda-setting, rather than sweeping reform, if they control only one chamber of Congress. The vast majority of attendees believed that the next opportunity for broad health reform – regardless of party control – will be in 2020.

Until then, it appears that states’ major goals for the upcoming year are to stabilize their markets and pursue strategies that protect exchange consumers through turbulent policy changes. We look forward to next year’s conference to learn new research findings and see how states navigated 2019.